A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Administer intravenous pain medication.

Draw blood for a complete blood cell (CBC) count.

Insert an indwelling urinary catheter.

Inspect the mouth for signs of inhalation injuries.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This choice is incorrect because administering intravenous pain medication is not the priority action for a client who has sustained partial-thickness burns. Pain medication may be indicated for pain relief and comfort, but it does not address the potential life-threatening complications of burns such as shock, infection, or respiratory distress.

Choice B Reason: This choice is incorrect because drawing blood for a CBC count is not the priority action for a client who has sustained partial-thickness burns. A CBC count may be useful to monitor the hematological status and detect any signs of infection or anemia, but it does not address the immediate needs of the client

Choice C Reason: This choice is incorrect because inserting an indwelling urinary catheter is not the priority action for a client who has sustained partial-thickness burns. A urinary catheter may be necessary to measure the urine output and assess the renal function and ﬂuid balance, but it does not address the most urgent problem of the client.

Choice D Reason: This choice is correct because inspecting the mouth for signs of inhalation injuries is the priority action for a client who has sustained partial-thickness burns. Inhalation injuries are caused by inhaling hot air, smoke, or toxic gases that damage the airway and lungs. They can cause airway obstruction, bronchospasm, pulmonary edema, or respiratory failure. Therefore, the nurse should inspect the mouth for signs such as soot, singed nasal hairs, burns on the lips or tongue, hoarseness, stridor, or wheezes. The nurse should also monitor the oxygen saturation and arterial blood gases to assess the oxygenation and ventilation status of the client.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.

Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreﬂexia or relieve the symptoms.

Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreﬂexia.

Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.

A. Contact the provider for further orders. B. Notify the blood bank of the discrepancy. C. Administer the blood as ordered. D. Complete an incident report.

Correct Answer is C

Explanation

Choice A: Contacting the provider for further orders is not necessary, because the client has type AB blood, which is compatible with any other blood type. The client can receive type B blood without any adverse reactions.

Choice B: Notifying the blood bank of the discrepancy is not required, because there is no discrepancy. The blood bank sent the correct type of blood for the client, according to their blood type.

Choice C: Administering the blood as ordered is the correct action, because type B blood is compatible with type AB blood. The client will not have any transfusion reactions or complications from receiving this type of blood.

Choice D: Completing an incident report is not appropriate, because there is no incident. The nurse did not make any error or mistake in administering the blood to the client. There is no need to document or report anything unusual.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

Here is the edited text: A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 is 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base imbalances?

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make?